OCD TREATMENT: FIGHTING BACK
By Laurie Krauth, MA

000A young executive can't wear clothes until they are put on "just right." He loses his job because it takes him so many hours to get dressed.
000A new mother is terrified that her blasphemous thoughts will kill her infant. So she stands over his crib repeating, "I love you Jesus" six times. If she's distracted, she starts again. And again.
000A football coach is afraid that his aunt will die in a car crash if he does something wrong - but "wrong" keeps changing. One day it means thinking of her as he puts on his favorite jersey, the next it means picking up a box of cereal at the grocery store with an expiration date that adds up to his aunt's birthday.

If you have Obsessive-Compulsive Disorder (OCD), you know why it's called the "doubting disease." Your obsessive thoughts cause your anxiety to soar. You try to calm yourself by doing rituals that make no sense to you intellectually. Still, you fear that if you don't do what the OCD is telling you to do, something will go very wrong. No matter how smart, logical or compassionate you are, you are blackmailed by the irrational thought that the OCD may be telling the truth, and the stakes are too high to ignore it.

DECIDING TO SEEK TREATMENT
You've had enough of being blackmailed by your OCD. You want your life back. You decide to take on your OCD and go through the painful, exhilarating process of gaining mastery over your symptoms. You understand that you may never be entirely free of your obsessive thoughts. That you may find, in periods of stress, your OCD regains some strength. But you know you can minimize its place in your life overall.

You've found a therapist who specializes in cognitive-behavioral therapy, or CBT (the treatment that has scientifically demonstrated to be effective for treating OCD). She tells you she's going to work with you using a specific kind of CBT with yet another set of initials, called exposure and ritual prevention, or E/RP.

"Your mind and body have been held hostage by your OCD symptoms but you can choose to fight back," she explains. "You can break the connection between your anxiety-producing obsessions and the irrational rituals meant to eliminate them. Then you can see, first-hand, nothing bad happens."

"But I've tried to fight back a million times," you reply. "I always end up back in the throes of OCD."

"I'm sure you've tried hard," your therapist agrees. "We're going to use your motivation and help it along with a structured, systematic program that will allow you to confront your fears without ritualizing.

MAPPING OCD'S ROLE IN YOUR LIFE
To start, you and your therapist complete a comprehensive assessment, covering your history and other relevant concerns. You start by examining your symptoms today. You say you worry about harming others, and it shows up in a variety of checking symptoms.

"I'm afraid I'll run people over with my car, and at home I'm afraid I'll burn my house down by leaving an appliance or the lights on," you tell your therapist. "Every time I drive past a pedestrian, I look back for a body. When I get home, I repeatedly check the locks, the stove burners, the lights. It's exhausting - and it makes me feel crazy."

Your therapist gives you your first assignment. "Over the next week, play detective. Record on a sheet all of your obsessive worries and notice exactly what you do in an attempt to make them go away."

"It's even worse than I thought," you tell her when you return the next week. "I realize that when I'm driving past someone, I listen for the thump of a body going under the wheel. When I get out of the car, I pass my hand over the body of the car to feel for new dents or skin or hair from someone I hit. Then I switch on the news at home to check for any reports of hit-and-run accidents where I drove."

"Those were behaviors aimed at neutralizing the anxiety caused by the obsessive fear of hitting someone," she explains. "Did you notice any situations or thoughts you avoided so you wouldn't trigger your OCD?" she asks.

"I realize I drive blocks out of my way in the morning so I won't pass elementary school kids walking to school," you say. Your obsessive thoughts, rituals and avoidance behaviors have become so habitual that you've stopped noticing them. "My OCD controls me even more than I realized," you say flatly.

USING YOUR MIND AS A WEAPON AGAINST THE OCD
"Of course, everybody has bad thoughts," your therapist explains. "What makes it hard for you is how long you spend worrying and trying to drive the demons away, and how much that affects your life. Most people let those bad thoughts go, deleting them like spam from their computer. For you, the thoughts won't let go. The OCD convinces you that your rituals will make the bad feelings go away - they'll make things right or keep you or someone you love safe - so you keep doing them."

"It's like a triple whammy," you reply. "I'm upset by these thoughts and I'm mad at myself for taking them seriously, but I'm afraid to skip the ritual just in case it really works. Then I'm frustrated with myself for doing things that make so little sense!"

"OCD is like a hungry, barking dog," she comments. "When you do your ritual to make the bad feelings go away, it's like you feed the dog a steak to get it to leave you alone. Instead it just gets louder, looks tougher and is more insatiable. You feel like you better feed it bigger and juicer steaks, more often, to keep it from harming you.

"I've noticed that," you say. "I used to check my rear view mirror once, and now I need to check it three times to get any relief. And even that doesn't last."

"Well," she replies, "you've come in for treatment because you've decided to stop feeding the dog steak. You're going to be doing something very different by standing up to that snarling dog. You'll discover that it's bluffing."

PLANNING YOUR TREATMENT STRATEGY
You discuss with your therapist whether to combine medication with the cognitive-behavioral therapy. She explains that a psychiatrist could consult with you about medication. Some people with OCD benefit from combining medication and CBT.

You and your therapist begin preparations for the exposure and ritual prevention program. Together you create a detailed inventory of all your obsessive thoughts, rituals and avoidance behaviors. You rank your compulsions by the degree of distress it causes you to experience the obsession and imagine not doing the desired ritual.

Your first assignment is to target a situation you really want to change. That will motivate you to do the hard work E/RP demands of you, your therapist explains. But you don't want to pick something so overwhelming that you aren't willing to do it, she says.

"I want to start with driving," you reply. Together you make a plan that will be hard - but not too hard. "The first week I'll drive an hour a day on the highway in the right lane, looking for opportunities to drive near cars or people on the side of the road. I won't use my 'safety crutches' like looking in my rear-view mirror for bodies or checking for dents after I leave the car."

You'll increase your anxiety by adding exposure to your bad thoughts. You place sticky-notes on the dashboard. They read: "I hit someone." "There's blood on my grill." "I killed someone." You agree you won't stop the assignment each day until you feel less anxious than when you started. You'll record your anxiety and success for each E/RP session on a form.

You've scheduled a double session with your therapist so that when you finish the planning, you can go out in the car together. "In this therapist-assisted E/RP, I can help you practice the work you'll be doing on your own," she says. "We'll do something a little harder than your assignment while I'm here to give you support. That will make your daily homework less daunting."

For the next hour, she sits beside you while you drive on the highway, changing lanes repeatedly to increase your anxiety about hitting someone and then not looking in your mirrors to check. Your anxiety spikes at first but diminishes over the hour, and you head home confidently to begin your own E/RP.

After three days of assignments you report on your progress to your therapist. "It was easier than I expected, but I still glanced back in the mirror several times each day. And I asked my wife for reassurance a few times when I got home," you acknowledge.

"That's good information," says your therapist. "Continue the exposure but really put the brakes on seeking reassurance. How about adjusting the mirrors at a slightly awkward angle - just enough to interrupt your reflexive checking? And work hard not to ask your wife for reassurance."

At your next appointment, your wife comes in to learn how to offer support without giving you the reassurance that ends up hurting, more than helping, you. "It may feel awkward at first, but the best way to help is to let him experience the anxiety that comes with exposing himself to his fears," your therapist tells your wife. "That way he learns that he can handle them and that his fears are unlikely to come true." She helps you and your wife find some possible new lines: "It sounds like your OCD is really getting to you" or "It's hard to resist but you're really trying." She adds: "You might feel badly for him, or even get impatient for him to get better faster, but it's up to him. You don't need to be his therapist. All you can do is encourage him and step back."

You and your therapist modify your assignment to improve your compliance. "OK. I'll laminate little post-it notes with the words, "It's not me, it's my OCD" and tape them to my car's rear view and side mirrors to make me more conscious of not checking them," you say. You also re-commit to zero tolerance of rituals or avoiding situations that bring up your obsessive thoughts. You're more successful this time, and when your anxiety diminishes with this task, you're ready to add a harder assignment that you craft with your therapist.

"Next I'm going to drive at least an hour a day in areas where I'll probably see pedestrians on the road," you summarize at the end of the next session. "I'm scheduling trips past schools at 8 a.m. and 3 p.m. When the anxiety goes down with this assignment, I'll move up the list to a more challenging task: driving at dusk, when it's harder to see pedestrians and I get more anxious."

Within a month you are driving places you hadn't imagined possible without depending on your checking rituals. You're feeling increasingly optimistic about your ability to control your OCD. But you want to make sure this isn't false confidence.

"I wonder if I'm calmer because I'm avoiding those scary thoughts that make me want to check and get reassured," you tell your therapist. "I know a way to find out," she says. So you add another layer of homework: mental exposure to the feared thoughts. She helps you write and then tape-record a script about a worse-case hit-and-run scenario:

"I hit a bump. I've run over a body. I hear a police siren. They're coming for me. I'm sweating as I pull over on the next block. I check the grill on my car: I see skin, and can smell blood. I turn on the radio; already they're reporting my hit-in-run. I'm sure I'll go to prison." The story goes on.

You commit to spending an hour a day with twenty minutes each of reading the script, writing it out and listening to it. At first your anxiety spikes, but over time it becomes almost boring ("This is ridiculous. That just wouldn't happen!" you think.). Eventually you can drop it from your daily E/RP tasks.

Now you're significantly less anxious during and after each trip out. Over the months you continue moving up to increasingly difficult tasks. Still, your progress is uneven, depending on how stressful your life is and other occasional bumps.

"Sometimes I want to quit," you admit to your therapist at a session. "I'm so much better and sometimes I think I'd rather just accept my progress and make life easier by giving in to a few rituals when I'm having a bad day."

"Standing up to your OCD can be exhausting," she said. "And yet if you feed that hungry dog an occasional steak, do you think that would satisfy it?"

"No," you reply. "And honestly, that's what keeps me going when I'm tempted to take a break. That insatiable dog will always want more and I'm done being held hostage by it. I've gone cold turkey on my rituals and I'm committed to staying with this, but I'm going to need help."

Together you fine-tune your treatment plan to help you maintain your momentum and get the support you need. Your success motivates you and you continue to gain mastery over your OCD. The work is challenging and time-consuming and you know you still have more work ahead of you. But your courage is bringing you a reward that is life changing and indescribably sweet.

Laurie Krauth, MA, is an Ann Arbor, Michigan, psychotherapist and ADAA member specializing in cognitive-behavioral therapy with anxiety disorders, including OCD. She also treats depression and trauma and works with couples on relationship issues. Links to more information on the treatment of OCD and other mental health issues can be found at www.LaurieKrauth.com. To protect confidentiality, case descriptions in this article are based on composite or fictionalized clients.